In 1995, sales in the United States of behavioural drugs -
which include anti-depressants, anti-psychotics, hormone therapies
and stimulants - were valued at $6bn. In 2002, they were worth $23bn
- an almost fourfold increase in eight years. And in the big five
European countries - Germany, France, Britain, Italy and Spain -
during the same period, sales of such drugs more than doubled to
$7bn. This vast growth in sales of drugs that modulate our behaviour
and our sense of self has turned the pharmaceutical business into
the world's most profitable since well before the
1990s.

Two developments, subtly but powerfully related, have changed
the nature of our relationship with prescribed drugs forever. The
first is what David Healy, historian of pharmacology, calls "the
medication of risk". Where in the past people became ill and were
then prescribed drugs, today they are medicated to prevent illness.
This is an extraordinarily profitable enterprise. Last year, the
world's top-selling drug was an anti-cholesterol agent called
Lipitor, which brought in revenues of just under $8bn, more than any
drug in history. Its main competitor, the world's second-biggest
selling drug, Zocor, reported sales of more than $6bn in 2002.
Although cholesterol medications are intended only for those who
have tried and failed to control their condition with diet and
exercise, more than 10 per cent of US adults and a rising share of
Europeans are taking or have taken them.

The second development, the one that this article addresses,
is the vastly increased role for compounds that modulate emotions
and behaviour. To anxiety and sleeping pills has been added the
commercial colossus of depression, which generated worldwide sales
of $16bn in 2002, and therapy areas such as attention
deficit/hyperactivity, hormone replacement and sexual dysfunction.
Each is worth billions. Products for three elusive goals - weight
loss, smoking cessation and memory enhancement - are on the horizon,
as are medications for nervous states such as social anxiety
disorder, generalised anxiety disorder and, in children,
oppositional defiant disorder. Drugs to hit these "targets" (a
favourite industry term) will come to market in the next two to four
years.

The behavioural drugs industry is being both pushed and
pulled forward. Shareholders expect pharmaceutical companies to
return an exceptional 17 or 18 cents on each dollar, so companies
tend to focus on medicines that people will take for long periods
and that treat conditions with elastic diagnoses. Origination of the
drugs is now cheaper: start-up biotechnology companies conduct
research and then license their developments to big corporations.
The real competitive fight among the multinationals is in selling
medicines in "blockbuster" quantities - products with sales of more
than $1bn a year - before their patent protection expires, usually
within a decade of launch.

These corporations play to two audiences: doctors, who are
under increasing pressure from governments and insurers to reduce
their (relatively expensive) time with patients while budgets for
(relatively cheap) drugs increase; and consumers - no longer mere
"patients" - who are alerted to their full universe of potential
ailments by public education, lifestyle journalism and corporate
advertising, and who demand maximum access to such treatments. Even
in Europe, the days of the meek and easily gratified National Health
Service recipient are long gone. Pharmaceutical companies have
responded by offering medicines that increase doctors' patient
throughput and go as far as possible towards meeting consumers'
demands for complete healthcare - typically the behavioural drugs
that already account for between 10 and 50 per cent (as in the case
of Eli Lilly, originator of Prozac) of the revenues of big
pharmaceutical companies. And the business is growing fast. "This
decade," Healy predicts, "is about lifestyle
drugs."

Some argue that the terms "lifestyle" or "quality of life"
drugs insult those who suffer from pathological conditions such as
depression, schizophrenia, obesity or compulsive behaviour, so we
will use the term "behavioural drugs". They have three defining
characteristics - first, behavioural medications treat diseases and
disorders that depend largely on a doctor's judgment. As Dr Jim
Kennedy, chair of the prescribing committee of Britain's Royal
College of General Practitioners, puts it: "There's no simple blood
test for anorgasmia or for attention deficit." Where there are
physical symptoms of a behavioural condition - as with obesity - it
is also a highly subjective judgment as to whether the condition is
pathological or self-inflicted. Second, and perhaps most striking,
behavioural drugs in clinical trials always produce a significant
effect in placebo. Finally, although behavioural drugs are marketed
with the conviction and scientific certainty that modern sales
techniques require, their mode of action is poorly understood. In
private, industry researchers concede they don't know how most of
the drugs work. Many have been discovered by accident - most
famously, Viagra was developed to treat chest pain but turned out
instead to give men erections.

The behavioural drugs era began with the first anti-psychotic
- called Largactil in Europe and Thorazine in America - in 1952. The
compound was given to thousands of acutely afflicted patients,
particularly schizophrenics, who were locked up in asylums in Europe
and north America. It helped many return to normal life. Yet when
Geigy (now part of Novartis) came up with the first anti-depressant
- later branded Tofranil - it dithered for years about whether to
develop it. There was no captive market in institutions, and the
industry consensus was that depression was an uncommon ailment
unlikely to respond to medication. But industry misread the market.
People badly wanted depression drugs, and in 2002, the US ranked
five anti-depressants among the nation's 20 best-selling
medications.

The story was similar in what is currently the most
controversial therapy area in behavioural drugs: attention deficit
hyperactivity disorder, or ADHD, in children. Ritalin, the drug
popularly associated with this condition, was patented more than 20
years ago when the drugmaker, also now part of Novartis, believed
its potential market to be tiny. Jo Ellins, who is researching the
history of three behavioural drugs - Ritalin, Prozac and Viagra -
says: "Novartis almost didn't promote Ritalin... Ritalin has been
much more driven by parents and schools." The boom in Ritalin
prescriptions in the US coincided with a period in the early 1990s
of expanded class sizes, universal rejection of physical punishment
of students and special funding for schools that identified children
with disabilities such as ADHD. More than anything, Ellins dates the
the Ritalin phenomenon to what she calls a "whispering campaign"
among parents about what it achieves: it calms down
difficult-to-manage, sometimes impossible-to-manage, children.
Andrea Bilbow, who runs the industry-supported National Attention
Deficit Disorder Information and Support Service (ADDISS) in
Britain, sums up the proposition for parents who feel they have lost
control of their usually male offspring: "What would you rather do,
beat your children into a pulp or give them
medication?"

Stressed parents wanted Ritalin as other people wanted
anti-depressants. Novartis had opened up a market - largely (since
by that time Ritalin was nearly out of patent) for the benefit of
other drug manufacturers. One company to benefit was the UK-based
Shire Pharmaceuticals Group, whose extraordinary story is the real
one of the 1990s: not that Big Pharma invented the behavioural drugs
market, but that having identified the demand, it began to sell its
wares in a much more... well, clinical, fashion.

On a sunny Wednesday morning in the Hampshire International
Business Park, Angus Russell, Shire's chief financial officer,
recalls how his London commuter-belt company revolutionised the
manner in which stimulants are marketed to children in the US. Shire
was a medical marketing company that in 1997 bought the rights to a
failed juvenile obesity drug w that researchers had noticed had a
calming effect on children. The compound, which works like Ritalin
to enhance concentration, was repositioned as a treatment for ADHD.
Whereas Ritalin had to be taken through the day, however, Shire
brought in proprietary slow-release technology that meant its
product, Adderall, need only be taken before and after school. As a
result a child's peers would not know they were taking drugs, and
schools need not have substances on their premises that could be
abused. "The big selling proposition," says Russell, "was you can
avoid the midday, in-school dose." More important, though, was the
manner in which Shire sold the product in the US. It gathered
together all available data on the 180,000 US-based clinical
psychiatrists, paediatricians and general practitioners who had
prescribed an attention deficit drug. By using information about
prescribing histories that only became computerised and commercially
available in the 1990s, it was able to identify a sub-group of
27,000 doctors who had written 80 per cent of ADHD scrips. Within
this group tiers of American physicians were selected according to
the volume of drugs they prescribed. A sales strategy was mapped out
accordingly. "We literally treat it as a pyramid," says Russell.
"The first 1,000 physicians probably prescribe 15 per cent of the
market. The top 1,000 get 35 visits a year."

During those visits, Shire's 360 sales representatives stick
to a tight script about the merits of their product. Busy doctors
may spare them only a couple of minutes. "A lot of people say you
have to have scientifically trained people," Russell says. "Our head
of sales says: 'Just give me sales guys.'" The strategy has been
phenomenally successful. Among the top 1,000 ADHD prescribers in
America, Shire claims a 40 per cent market share by value, compared
with 23 per cent overall. Back in 1994, Shire's venture capital
backers decided to take the company public, setting a target
valuation of $500m by 2000. That year Shire was worth $8bn and today
it ranks as one of the top 100 UK listed companies. About 700,000
children of the three to four million in the US on ADHD drugs are
taking Adderall - a product that is not sold in Europe, where the
company deems it too early to begin promotion. In 2002, Shire
produced net earnings of more than $250m from revenues of only just
over $1bn.

Medication of ADHD in the US is growing faster than ever - by
18 per cent in 2003. "We've driven that market," says Russell
proudly. Two giants of the behavioural drugs industry, Eli Lilly and
Johnson & Johnson, recently launched new ADHD drugs, which
suggests they believe the business is far from saturated. Shire is
about to launch Methypatch, which uses the same slow-release
technology employed in nicotine patches but instead delivers
methylphenidate, the off-patent compound behind Ritalin. The
Methypatch can be applied for a few hours if a dose of medicine is
forgotten, avoiding the need to give a child a pill late in the day
that will keep it awake at night (as stimulants
do).

The biggest prize on the horizon, however, is adult ADHD. In
2002 Eli Lilly's ADHD drug Strattera was the first to receive
approval from the US Food and Drug Administration (FDA) for adult
attention deficit. Shire has applied to market Adderall to adults in
America in a country it claims has at least eight million potential
patients over 18, versus at most four million ADHD-diagnosed
children. Moreover, unlike children, adults can present themselves
for evaluation - a factor that is likely to accelerate the already
stunning growth of the business.

The Shire story illustrates the broader marketing revolution
that took place in the pharmaceutical industry in the 1990s. The
number of sales representatives in America trebled during the decade
to 90,000, with a similar trend in Europe. Jean-Pierre Garnier,
chief executive of one of the largest pharmaceutical companies,
GlaxoSmithKline, told the Wall Street Journal recently that his
sales machine is now so big it can reach the prescribers of
four-fifths of all drugs in the US within a week. The industry's
conferences have become vast jamborees to which doctors are invited
on an all-expenses-paid basis. The European College of
Neuropsychopharmacology (ECNP) Congress in Prague last September
attracted 3,000 psychiatrists - less than half the size of the
lodestar conference, the annual gathering of the American
Psychological Association, held each May. In Prague, Nancy
Andreasen, editor of the widely read and supposedly independent
American Journal of Psychiatry, signed copies of her new
Introductory Textbook of Psychiatry on the Eli Lilly stand. For four
days there were sponsored lectures about how to cure behavioural
conditions with drugs, at which the speakers did not state how much
they were being paid to speak or by whom. Posters were displayed by
non-industry scientists highlighting the results of breaking
research which, the small print usually advised, was sponsored by
industry. Game show techniques are creeping in. Rising behavioural
drugs star Sanofi-Synthelabo of France invited psychiatrists to
undertake the "Solian quiz". They had to answer 10 questions, most
of the answers underpinning the use of Solian (an anti-psychotic
drug): depending on score, they walked away with a desk lamp or a
modish French radio bearing the Sanofi logo.

The doctors this correspondent talked to said they were much
too clever to be taken in by this kind of thing. But it would be
curious if the industry bankrolled these conferences without
shifting product. One of the best allegories for the trends in
behavioural drug marketing is the development of sales strategies
for treatments for erectile dysfunction. Viagra's first sponsored
spokesman was the grandfatherly former US presidential candidate Bob
Dole, who suffered prostate cancer, a condition closely associated
with impotence. However, as the scale of the potential market for
such a product became apparent, Rafael Palmiro, a Texas Rangers
baseball star, took over, and the message changed. "They were
saying: 'He hits it out of the park,'" says Katharine Greider,
author of The Big Fix, about pharmaceutical marketing. Today, the
message has moved on again. One of Viagra's two new competitors,
Levitra, is running television advertisements where a young couple
are fooling around amorously in their yard. The man hurls a football
through a suspended tyre with striking accuracy. The punch line
follows: "When you're in the zone, it's good."

Big Pharma, though, can't sell us things we do not want. We
possess an irrepressible belief that chemical solutions exist to
life's problems: this is what makes the business so big. Gerard Le
Fur, the long-standing research director of Sanofi, has a vision of
where the industry is going and how much bigger it might become. His
company, based at art-laden headquarters on Paris's left bank, has a
hotly tipped drug in final stage trials that works on the brain's
cannabinoid receptors - those excited by marijuana. It may be a
harbinger of a brave new world to come.

Fifteen years ago Sanofi was among the first companies to
begin artificial cloning of "receptors", the molecules that occur in
the brain and other parts of our bodies that affect mood, emotion
and behaviour. Receptors are the chemical "targets" that can either
be hit to increase their excitation with an "agonist" or blocked, to
decrease their activity, with an "antagonist". The research game is
to identify a target, shoot it or block it with a new compound, and
thereby modulate human behaviour. In the 1980s the big
multinationals invested heavily in automated and computerised
systems that allow endless testing in the laboratory, without human
trials, by hitting a cloned receptor with every imaginable dose and
variant of a compound. "High throughput screening" has not generally
produced the breakthroughs the industry predicted - because, say
some scientists, it is a grossly simplistic approach to something as
complex as human behaviour - but it may have worked for
Sanofi.

Le Fur decided early on that he wanted to clone the main,
cannabinoid-1 receptor that occurs in our brains and guts. Aware of
the cannabis "munchies" effect that leads some people to gorge
themselves when high on marijuana, he wondered what a blocker would
do. "It's well known that marijuana smoking stimulates appetite and
we just wanted to have the opposite," he says. Le Fur was also
intrigued by the effect of marijuana on schizophrenia, a condition
it can exacerbate by causing hallucinations. He thought there might
be therapeutic benefit for schizophrenics in blocking the
cannabinoid receptor.

With the isolation of a compound now branded as Rimonabant
the schizophrenia hunch proved to be wrong. But in animal and early
human trials, obese rats lost weight. Not only this, they shed
weight in part by losing their interest in fatty, unhealthy foods
while maintaining their desire for adequate protein. The drug also
appeared to reduce pleasure derived from - and hence appetite for -
nicotine and even alcohol. "Through blocking the cannabinoid
receptor in animals we got blocking on smoking, obesity and
alcohol," says Le Fur. The findings on smoking and weight loss were
confirmed by human trials. Final-stage trials with 12,000
participants for smoking cessation and obesity will complete next
year.

If the trials end successfully, Sanofi will have a drug for
weight loss that may work by making us eat more healthily. It will
have a drug for smoking. It could have a drug - trials are at an
earlier stage - for alcohol dependency. Above all, Sanofi would have
a drug for giving up smoking and losing weight at the same time. It
would be a fantastically attractive commercial proposition. Asked to
tip a winner among near-term behavioural drug pipelines, Nigel
Barnes, a pharmaceuticals analyst at Merrill Lynch, offers simply:
"Sanofi".

But the very scale of such potential success underscores why
medical ethicists, police and parents are wringing their hands about
diversion and abuse of behavioural drugs. We live in a world where
Viagra - which even Healy, a fierce critic of the behavioural drugs
industry, says was a breakthrough, life-changing medication for
genuinely impotent men - is sold in nightclubs. Children steal
Ritalin and Adderal to crush up and snort for party fun or as an
exam-cramming aid. Anti-depressants, particularly selective serotin
reuptake inhibitors (SSRIs) such as Prozac, are taken by people who
could do without them. The earliest of a new generation of
memory-enhancing drugs for Alzheimers are already being diverted in
significant quantities in the US to people seeking a cognitive
upgrade. Rimonabant, if approved for sale, will doubtless be used by
slightly overweight people who want to shape up and quit smoking for
a couple of months. As Le Fur puts it: "I'm a scientist. I work with
pathological states. But I can't say that Rimonabant will only be
given to obese patients." The internet has aided this diversion of
drugs - everything from Viagra to Prozac is available on the web,
dispatched in discreet packaging with no questions asked. The trade
has proved impossible to regulate. It is unsurprising that there are
those, such as the social critic Francis Fukuyama, who point to a
new "Age of Aquarius" in which the drugs are supplied not by
hippies, but by Big Pharma.

This may not, however, happen soon. The history of
side-effects of behavioural drugs has been ugly. It is only our
hunger for chemical solutions that allows us, periodically, to
forget this. Henry A. McKinnell, chairman and chief executive of
Pfizer - by far the biggest pharmaceutical company in the world and
maker of Viagra and Zoloft - concedes: "There are no free lunches in
medicine." The story of the benzodiazepines - Librium, Valium,
Mogadon and Ativan - that were launched principally for anxiety in
the 1960s and 1970s has been so appalling, Healy says, that the
pharmaceutical companies dared not even talk to doctors and patients
about anxiety for most of the 1980s and 1990s. Instead, in marketing
terms, we entered the era of depression. "Companies were forced to
market products as anti-depressants as there was such a reaction
against benzodiazepines," he says. "In the 1980s the companies would
have preferred to bring the SSRIs on as anxiolytics [anti-anxiety
drugs], but the benzodiazepine fuss made this difficult. The doctors
were awfully twitched."

The doctors were "twitched" over a situation where, for
example, in the UK in 2003 - the 40th anniversary of the launch of
Valium - half a million people were still long-term dependents of
benzodiazepines, drugs now reckoned so addictive that official
prescribing guidelines say they should not be taken for more than 28
days in succession. Data from coroners' reports compiled by the Home
Office show benzodiazapines a much more frequent contributing factor
in cases of unnatural death each year than are cocaine, heroin,
ecstasy and all other illegal drugs. Prescriptions of
benzodiazepines peaked in 1977 in the UK at 30 million, yet in 2002
there were still 12.5m. The story is the same, only the numbers are
bigger, in the US. Alprazolam, a benzodiazepine originally marketed
by Upjohn (now part of Pfizer) as Xanax, was the 11th most
prescribed drug in America last year, ahead of top SSRIs such as
Zoloft and Paxil. Alprazolam does not make it on to the US top 20
drug list by revenues because it is off-patent and hence cheap, but
the drug - reckoned by many independent researchers to be among the
most addictive in its class - is consumed in massive
quantities.

Some of the worst horror stories relate to weight-loss
medications. The track record is so bad that the FDA now requires an
additional two-year review of patient health after the completion of
phase three trials of slimming drugs. This will delay the earliest
potential release of Rimonabant from 2004 to 2006. Doctors have been
prescribing patients stimulants - often amphetamines - for weight
loss for decades with unpleasant side effects. But the FDA changed
the rules after the US company Wyeth introduced a stimulant and
sedative combination in 1996 called Redux. The drug had an
aggressive sales launch and, in the less-than-18 months before its
withdrawal, managed to do so much cardiovascular damage to so many
people that Wyeth has set aside $12bn to settle legal
claims.

More recently Switzerland's Roche, originator of
benzodiazepines, launched a weight drug that makes fats pass through
the gut without being absorbed. Xenical looked like a blockbuster -
until people realised that eating too much fat while on the
medication (Roche did warn against such use) causes monstrous
diarrhoea. Its sales, in a perfect illustration of our impossible
desire to have cake and eat it, are falling precipitously. "Don't
wear a white dress to the opera after a fatty dinner on this one,"
opines one London pharmaceutical analyst.

The past two years have brought to light significant new
evidence and concerns about the side effects of behavioural drugs.
Large-scale public studies in both the UK and the US have shown that
women undergoing hormone replacement therapy (HRT) are twice as
likely as other women to suffer invasive breast cancer. Concerns are
also growing about the vast numbers of children who have been taking
ADHD drugs long-term - in the US, in many cases, for as long as 10
years. Long-term studies of side effects have never been conducted
in humans and senior policymakers are beginning to wonder if that is
not a dangerous thing. "It is a question I ask myself," says Nora
Volkow, the much-respected director of America's National Institute
on Drug Abuse and a specialist in brain chemistry. "It's
unacceptable in my view." Volkow is an ardent believer that ADHD,
properly diagnosed, is a serious illness, but she warns that animal
studies are flagging possible long-term impacts of medications on
the brain. Three such papers were published in the journal
Biological Psychiatry in December: "They highlight the need to do
research on this subject," she says.

In the US, lawyers are bringing a gradually escalating number
of cases against the makers of SSRI anti-depressants with respect to
suicides and other allegedly unmentioned risks. In the handful of
cases that have reached a jury verdict, the plaintiffs are winning.
In the UK in 2002, a Panorama documentary called "Secrets of
Seroxat" (the SSRI that is the market leader in Britain, sold as
Paxil in the US) elicited a record public response - more than four
million people watched the programme, 124,000 visited its website,
65,000 people phoned the BBC afterwards and nearly 1,400 wrote
e-mails describing suicides, attempted suicides and acute withdrawal
symptoms. Most worrying, even among those who wrote in support of
Seroxat - sometimes saying it saved their lives - two-fifths
reported serious problems coming off the drug. Jim Kennedy, from the
Royal College of General Practitioners, says, "We keep doing this.
We come out with a new drug that's a wonder drug. Then 10 years
later the repercussions come back and bite us on the
arse."

It is striking that benzodiazepines were marketed as a
non-addictive, low-side-effect alternative to barbiturates. SSRIs
were then marketed as the non-addictive, low-side-effect alternative
to benzodiazepines. The number of anti-depressant prescriptions in
the UK - most of them SSRIs - has reached 30m a year, the peak level
for the anti-anxiety benzodiazepines.

Charles Medawar, author of a book on benzodiazepines and a
strident critic of SSRIs, offers a bleak diagnosis: "The whole thing
is happening again," he says, claiming that the addiction and
side-effect profile of SSRIs will turn out to be worse than that of
the benzodiazepines.

"In qualitative terms I would say that the problems are much
more severe," he says. "You are trapped on a [SSRI] drug that has
nasty side-effects in weight gain and loss of libido. The
side-effects are much uglier than they were with benzodiazepines...
GlaxoSmithKline just changed the indicated incidence of withdrawal
problems for Seroxat from one in 500 to one in four." In December
the UK government banned the prescription of most SSRIs for
depression in children after finding that manufacturers had failed
to publish trial data showing increased risk of suicide; a
government review of SSRI side-effects in adults
continues.

Americans find the pessimism about drug use as depressing as
the conditions the medications seek to cure. "Look at Japan," huffs
Pfizer's Henry McKinnell. "They have the lowest anti-depressant use
and the highest suicide rate in the [developed] world." In Britain,
Professor Louis Appleby, national director for mental health,
concurs. He says suicide rates have reduced in the UK in the past 15
years while in countries that have made sudden switches to SSRI
drugs, such as Sweden and Hungary, there is incontrovertible
evidence that suicides have fallen as a result. "The main classes of
drugs in mental health have stood the test of time," he says,
"because their benefits have been greater than the problems they
cause."

Sales trends suggest that US versus European differences of
opinion over behavioural drugs will continue to see Americans
consume more than Europeans. But there is one point on which
everyone - chief executives, doctors, pundits and consumers - on
both sides of the Atlantic is agreed: people would prefer
non-pharmaceutical alternatives to cope with their problems if they
were available. Britain's National Association for Mental Health
(Mind) conducted a survey in 2002 which showed that 98 per cent of
people visiting a general practitioner regarding mental health
issues were given medication whereas less than 20 per cent asked for
it. Most people said the health system was not giving them enough
choice while many who sought alternative therapies had to find
practitioners themselves and pay for private
treatment.

Britain's public health system has begun to recognise this
basic truism. A restructuring of primary healthcare has, according
to Appleby, been accompanied by a 50 per cent increase in the number
of clinical psychologists since the mid 1990s, while half of general
practices in the UK have counselling services. In the US, the
situation is necessarily different. In general, the private health
system delivers the best healthcare in the world for those who have
insurance and something closer to third-world cover for those who do
not. But for all users, the US system tends to militate against
non-drug therapies in primary care. As McKinnell says, Americans get
an average seven minutes of their GP's time per visit. "Our system
creates an ironic incentive," says Katharine Greider. "You're under
pressure from insurers to keep costs down but there's a
contradictory pressure to prescribe. Writing a prescription is an
office-terminating event. It signals to the patient: 'It's time to
go away now'."

The US system is unlikely to undergo fundamental change in
the short term. In the 1990s, Bill Clinton tried and failed. But in
the US and in Europe there are increasingly vociferous demands for
more information about the drugs we consume. The structure of the
contemporary pharmaceutical industry means that drug companies
develop drugs, organise clinical trials - via physicians they and
their agents select - and then submit the results for approval to
the FDA (whose decisions tend to be followed by other regulatory
agencies). The companies' ownership of trial data - defined as
commercially critical information - allows them considerable
influence over the market. Mostly this occurs by omission: companies
tend not to release trial results that do not support their products
unless they are essential for regulatory approval. "The FDA," says
Healy, "audits rather like Arthur Andersen audited Enron. They
haven't got the resources to go further."

Healy points to the existence of quality of life (QOL)
scales, used for internal research by all the big pharmaceutical
companies. QOL scales employ more, and more diverse, data than are
required by regulators. They aggregate reports from clinicians as to
whether a drug remedies a specific problem and whether, on balance,
a drug has a positive impact on a person's overall well-being.
Critically, they also require data from patients as to whether they
believe a medication works and, again, whether it has improved their
life overall. Healy says he has identified almost 100 SSRI
anti-depressant trials in which QOL scales have been compiled but
less than a 10th have been made public. "In the quality of life
scales that have been published," he says, "the SSRIs come out
behind older drugs."

Few believe the behavioural drugs industry is a conspiracy to
defraud the public, but it is a profit-seeking business that has
shareholders as well as patients. In this context it is curious that
many expect higher standards of pharmaceutical companies than they
do of other corporations - it might be more realistic to take the
view that as behavioural science brings us new possibilities in
mental as well as physical health, personal choice is more important
than ever and consumers should be fully
informed.